Form Wcb-25 - Motion For Award Of Fees And Disbursements
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1MOTION FOR AWARD OF FEES AND DISBURSEMENTS
STATE OF MAINE
WORKERS' COMPENSATION BOARD
27 STATE HOUSE STATION, AUGUSTA, MAINE 04333-0027
1. INSURER FILE NUMBER:
6. SOCIAL SECURITY NUMBER (last 4 digits):
7. WCB FILE NUMBER:
XXX-XX-
2. EMPLOYER NAME:
8. EMPLOYEE LAST NAME:
9. FIRST NAME:
10. M.I.:
3. EMPLOYER MAILING ADDRESS AND PHONE NUMBER:
11. ADDRESS-NUMBER AND STREET:
4. INSURER NAME:
12. CITY:
13. STATE:
14. ZIP:
15. HOME PHONE:
5. INSURER MAILING ADDRESS:
16. DATE OF INJURY:
17. DESCRIPTION OF INJURY:
18. REASON FOR MOTION: (CHECK ALL THAT APPLY)
AWARD OF ATTORNEY'S FEES AND/OR DISBURSEMENTS (ATTACH ITEMIZED STATEMENT INDICATING DATES COVERED BY THIS MOTION)
AWARD OF WITNESS FEES
OTHER (EXPLAIN) ___________________________________________________________________________________________
19. AMOUNTS REQUESTED:
20. PAYMENT TO BE MADE TO:
ATTORNEY'S FEES:
$ ______________________
DISBURSEMENTS:
$ ______________________
NAME
WITNESS FEES:
$ ______________________
STREET ADDRESS
OTHER:
$ ______________________
TOTAL:
$ ______________________
CITY, STATE, ZIP
CERTIFICATION AND SIGNATURE (Motion Must Be Signed)
21.
I,___________________________________________________, hereby certify that I have caused a copy of this motion to be served upon counsel
for the employer, (or, if there was no legal representation, directly upon the opposing party) ___________________________________________
(Name)
at __________________________________________________________, on _____________________________________ by United States
(Address)
(Date)
mail, postage prepaid.
Signature ___________________________________________________
Date ___________________________________
ORDER
22. THE EMPLOYER/INSURER IS ORDERED TO PAY THE PAYEE NAMED ABOVE THE SUM OF $_______________________________
AS FOLLOWS:
$ _____________________________________ FOR ATTORNEY'S FEES
$ _____________________________________ FOR DISBURSEMENTS
$ _____________________________________ FOR WITNESS FEES
$ _____________________________________ OTHER PAYMENTS
______________________________________________________
_____________________
Administrative Law Judge
Date
The State of Maine provides equal opportunity in employment and programs. Auxiliary aids and services are available to individuals with disabilities
upon request. For assistance with this form, contact the ADA Coordinator at the Maine Workers’ Compensation Board. Telephone: 1-888-801-9087 or
TTY Maine Relay 711.
WCB-25 (eff. 1/1/13, rev. 10/15/15)
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